374604213-9-25-2023-18-AS-JSRS-CVZRDU-20230925125630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604213
Report Date: 09/25/2023
Date Signed: 09/25/2023 12:56:44 PM

Document Has Been Signed on 09/25/2023 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SACRED HEART HOME CARE		FACILITY NUMBER:	374604213
ADMINISTRATOR:	DOMINGO P IMSON JR		FACILITY TYPE:	735
ADDRESS:	829 BEGONIA STREET		TELEPHONE:	(760) 975-3849
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY: 4		CENSUS: 1	DATE:	09/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Emma Imson, Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to conduct the required annual inspection. LPA was greeted at the door by Caregiver, Ludivina Frogoso and explained the purpose of the visit. Administrator, Emma Imson arrived shortly. Present at the facility were two (2) staff and one (1) client. LPA was informed the three (3) other clients were attending a day program. A tour of the facility was conducted inside and out. Client and staff interviews were conducted as well. The facility is approved for four (4) Developmentally Disabled adults ages 18-59; all of whom must be ambulatory. The facility is a one story 4 bedroom 2 bathroom home. Two clients share a room and two clients have private bedrooms. There is also a bedroom designated for live-in staff. LPA observed clients bedroom furnishings to be in good repair with adequate lighting. Furniture throughout the house was observed to be in good condition. Clients have clean linen in good repair and sufficient hygiene products to meet their needs. All required postings are placed in a prominent area. Facility's Administrator certificate was renewed prior to 03/26/2023 but has not been received yet. Dues are shown as current. Facility has multiple operating dual smoke alarms and carbon monoxide detector that meet statutory standards. Fire extinguishers were examined and determined to be in compliance. All inside and outside passageways are clear of obstructions. There are no pools or bodies of water observed. According to Administrator, no guns and/or ammunition are stored on the premises. LPA observed the kitchen area to be clean and odor free with sufficient dishes and glassware. A two day supply of perishable, and a seven day supply of non-perishable, food items were observed. Hot water was measured at 116.5 degrees F. Temperature in the facility was 74 degrees. There is a locked storage area for medication. Chemicals and poisons are stored in a locked area, separate from food supplies. Continue on LIC809C

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SACRED HEART HOME CARE	FACILITY NUMBER: 374604213
	VISIT DATE: 09/25/2023

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Continue from LIC809

LPA reviewed current staff files and all staff are properly associated to the facility. Client records were reviewed and contained required documents. IPP and Physician reports are current. LPA reviewed P&I logs, records are balanced. P&I funds are kept separately from facility funds. LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided Administrator Emma Imson.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

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